Membership Registration and Privacy Form – Regency Calisthenic College

Member Information

Member Name*

First Last

Member Birth Date*

Are you over the age of 18?*

Yes
No

Please Select Membership Type*

Tots (3-4 Years)
Tinies (7 Years & under)
Sub Juniors (10 Years & under)
Juniors (13 Years & under)
Intermediates (16 Years & under)
Seniors (16 Years and over)
Masters (26 Years and over)

Address*

Street Address City State Postcode

Contact Phone*

Email*

Enter Email Confirm Email

School/Pre-School Child Attends*

Work Phone

Mobile Phone

Mother/Guardian Name*

First Last

Mother/Guardian Work Phone*

Mother/Guardian Mobile Phone*

Mother/Guardian Occupation*

Father/Guardian Name

First Last

Father/Guardian Work Phone

Father/Guardian Mobile Phone

Father/Guardian Occupation

How Can You Help?

Volunteer Duties

Hold down CTRL to select more than one.

I can provide other skills or help to the club. eg Professional skills, first aid etc. Please give brief description below.

Disclaimers

Permission to participate*

Yes

I, the adult member named above, agree to pay all fees at the commencement of each term. I agree to abide by the association and club by-laws, codes of conduct and rules.

Permission to participate*

Yes

I give permission for the junior named above to enroll at Regency Calisthenic College.

I agree to pay all fees and levies at the commencement of each term.

I agree to abide by the association and club by-laws, codes of conduct and rules.

Insurance Warning*

Yes

Part of a members’ fee structure includes the Calisthenics Victoria annual registration and insurance fee which must be collected by Victorian Clubs.

It should be noted that Regency Calisthenics College does not provide any insurance of any nature for members at any time. It is recommended that members establish their own insurance covers for personal accident, non-medical, salary benefits and loss of earnings etc.

Liability Disclaimer*

Yes

I understand that the possibility of injury is inherent with participation in the sport of Calisthenics. I confirm that I and/or the member am/is in adequate physical condition and free of illness or other medical problems to allow me and/or the member to safely participate in the sport of Calisthenics.

I hereby release the Regency Calisthenic College (the “Club”) and all of its Coaches, Staff, Committee Members and Members from any and all liability for injury or medical problems incurred by myself /or the member while attending and participating in activities run by the Club.

I further agree to defend, indemnify, and hold harmless the Club, its affiliates and their respective Officers, Committee Members, Coaches, Staff and Members from and against all claims and expenses, including legal fees, arising out of my and/or the members participation in activities run by the Club.

Medical Information

Emergency Medical Information

Emergency contacts: eg. Neighbour, close friend or relative

Name*

Phone*

Name*

Phone*

General Information

Family Doctor*

Phone*

Address*

Street Address City State Postcode

Medicare Number*

Ambulance Subsciber*

Yes
No

Membership Number*

Private Health Insurance*

Yes
No

Company*

Membership Number*

Medical Information

Date of last tetanus injection or booster*

Drug Sensitivities

Eg. Penicillin, Aspirin

Allergies

Eg. Food, Eczema, Medicines

Recommended action to be taken

Does your daughter suffer from*

Asthma
Diabetes
Epilepsy
None

Recommended action to be taken*

Other Conditions

(eg.hearing, visual, physical disabilities) Please give details

Does your child regularly take any medication*

Yes
No

Please give details*

Consent for Medical Treatment*

Yes
No

MEDICAL AUTHORISATION: I, as legal guardian of the above mentioned junior member or as the above mentioned adult member, hereby give permission, in the case of illness or injury, which may occur in connection with training sessions or competitions organised and/or conducted by the association or club, to have a medical officer provide assistance and treatment to the member as deemed necessary. (Please advise of any medical information we should know).

I acknowledge by entering my name and email address below that I have read, acknowledged (by my tick in the relevant boxes) and understood the above paragraphs

Name*

First Last

Parent/Gaurdian or Adult Member

Email*

Privacy Information

Privacy Statement

I authorise the Club to forward the information contained on this form to:

Calisthenics Victoria Inc ("State Association")*

Yes
No

Australian Calisthenic Federation ("ACF")*

Yes
No

for use by them in the administration of the sport of calisthenics at state and national levels and in accordance with the respective objects of the State Association and the ACF.

I agree to:

The Club*

Yes
No

Calisthenics Victoria Inc.*

Yes
No

Australian Calisthenic Federation*

Yes
No

sending me information pertaining to programs and promotions conducted by them from time to time.

I acknowledge and consent to photographs and video footage being taken of me during my performance. I acknowledge and agree that;

Calisthenics Victoria Inc. & Other Competition Bodies*

Yes
No

The Club*

Yes
No

Australian Calisthenic Federation*

Yes
No

may use the photographs or video footage for training and promotional purposes without my further consent being obtained.

I consent to:

Calisthenics Victoria Inc.*

Yes
No

The Club*

Yes
No

Australian Calisthenic Federation*

Yes
No

using my image, likeness and also my performance, at any time to promote.
- the sport of calisthenics - the Club - Calisthenics Victoria Inc or the Australian Calisthenic Federation by and in, any form of media. Nothing in this paragraph grants any rights of ownership to me in the choreography of a performance for; - the Club - Calisthenics Victoria Inc - Australian Calisthenic Federation

I authorise the publication of my competition results.*

Yes
No

COMMUNICATIONS & TECHNOLOGY POLICY

Using the internet and electronic communication is essential for communicating with club members. We are committed to communication being appropriate and related to club business. When using technology we will ensure that members' privacy is protected, clear boundaries are maintained, and bullying and harassment does not occur. Any club member found to have sent inappropriate electronic communication, uploaded inappropriate website content or engaged in blogs or discussions that harass, offend, intimidate or humiliate members, may face disciplinary action as outlined in our member protection or other welfare policy or covered by our code of conduct. The full copy of out Communications & Technology policy can be downloaded from the following link. Members are requested to download and read the policy prior to continuing. (Members can also find a copy of the form in the members section of our website). Communication & Technology Policy

I hearby state that I have read the Communication & Technology Policy and note that as a club members I will be bound by its requirments.*

Yes

Members Name*

First Last

Date*

I

Name of Parent

am the parent or guardian of the registered member. I expressly agree to personally accept the conditions set out in this form both on behalf of the registered member and also my own right.

Date*